NEJM: CABG report cards show risks, but benefits may outweigh them

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Only five out of 221 U.S. cardiac surgery sites publicly reporting CABG outcomes were below average. Physicians and policymakers, however, question whether this type of accountability assists patients in “discriminating among sites of care,” wrote Timothy G. Ferris, MD, and David F. Torchiana, MD, in a perspective in the Sept. 7 issue of the New England Journal of Medicine.

These data, collected  by the Duke Clinical Research Institute, include 11 quality measures such as post-op renal failure, medical therapy at discharge/pre-op, risk-adjusted mortality post-CABG, prolonged intubation, rate of sterna-wound infection, incidence of stroke and CABG using internal thoracic artery. The facilities were rated on a three-star scale.

According to Ferris and Tochiana, of the Massachusetts General Physicians Organization, Massachusetts General Hospital in Boston, these data pinpoint which centers, if any, fall below, are equal to, or exceed the average national performance range. Over the past three years, 23 to 27 percent of sites have been identified as outliers that are either below or above the average.

Additionally, the system uses performance scores—a scale of 0 to 100—in four subcategories, which include 30-day survival after procedure or after discharge, complications, medication use and surgical technique.

“The move on the part of the STS [Society of Thoracic Surgeons] to make results public will certainly trigger a cascade of responses,” wrote Ferris and Torchiana. Specifically, sites that do not convey outcomes to the reporting system may come under scrutiny.

Since the first cardiac surgery report card was made public in New York in 1989, multiple efforts have been made by policymakers and associations to improve cardiac surgery.

But Ferris and Torchiana wrote that some consumer advocates “pushing for transparency may view this release as a glass four-fifths empty—given the selectivity and number of programs reporting—the external pressure has been critical in stimulating improvement efforts within the medical profession.”

Additionally, the authors said that these data could be a “double-edged sword for providers,” due to the fact that the quality-performance reports are often based on administrative data, leaving physicians to wonder whether or not these data are “flawed” and there conclusions “suspect.”

Ferris and Tochiana said that physicians fear “misclassification” within the public reporting system. But, the STS alleviated these concerns by reporting group-level rather than physicians-level data and ensuring the validation of data and risk-adjusted models.

While the authors said that a system of accountability is necessary to improve healthcare, they wrote, “Nonetheless, questions remain about the role of public reporting in improving healthcare.”

The authors noted that the STS data is reported in a way that “attempts to both inform patients and mitigate physicians’ fears,” and said that perhaps the Centers for Medicare & Medicaid Services (CMS) can learn from  such initiatives and apply them to upcoming “meaningful use” requirements and Physician Quality Reporting Initiatives.

“Insofar as public reporting drives improvement of all outcomes, it benefits everyone insofar as risk aversion leads to changes in the population receiving an indicated service, the net effect can be nil or even negative,” Ferris and Tochiana concluded.

The CABG ratings were released by the Society of Thoracic Surgeons and were published in the Sept. 7 edition of Consumer Reports